Inspection visit
Inspection
20 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, and interview, the facility failed to ensure access to telephone communication for
residents, family members, staff, and outside affiliates was easily available. This failure denied residents,
family members and medical staff consistent communication regarding the medical care for residents and
had the potential to result in a delayed or non-delivery of care and services to its residents.
Residents Affected - Few
Findings:
During an observation on 3/8/21 at 8:30 a.m., the screener (e.g., facility staff assigned to screen staff and
visitors for COVID-19 signs and symptoms as they come into the facility) was observed answering the
telephone and walking to individual staff to let them know they have a phone call.
During an interview on 3/11/2022 at 12:15 p.m., the Director of Staff Development (DSD) stated the facility
utilized a new telephone system, and she was trying to learn how it worked. When phone calls for a
resident come into the facility, the calls are forwaded to a satellite phone that was brought to the Resident.
Not all resident rooms had their own telephones.
During an interview on 3/10/2022 at 2:30 p.m., Resident 17's son was questioned about his mother's care
in the facility and if there were any concerns. Resident 17's son stated, the biggest problem was direct
telephone contact with the resident and the medical staff. The problem is inorder to get phone messages in
and out of the facility you must bring a cordless phone over to the resident. The phone will ring up to 30
times before someone answers and when someone answers they must put me on hold until they can
transfer the phone call to a portable phone that is brought to my mother. I have been disconnected several
times, then, when you try to call back, it's hard to get through. When asked if he had spoken with facility
staff or a Physician regarding this issue and his mother's care he stated, Yes, he had complained about the
telephone problem and asked what they can do so he can speak to staff or a Physician. Resident 17's son
stated, it is very frustrating, I wish they would fix this problem. I would like to know more about my mother's
care and have input into the plan for her care. There was a short IDT meeting this week on 3/8/2022, I
called into this meeting and all they told me was that they were changing my mother's medications. There
was no time on the call to ask questions or receive an explanation why they were making these changes. I
'm not sure if I agree with these changes. The first thing the facility needs to do is fix the phone problem and
the second is to communicate with me more about her care or any changes they want to make, I am her
DPOA (Durable Power of Attorney).
During a telephone interview on 3/4/22, at 9:41 a.m., the Ombudsman who had jurisdiction over the facility
stated that she avoided calling the facility during change of shift because she knew staff would be busy
during those times. She stated sometimes when she calls the facility if she needed to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
055853
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0576
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
talk to a staff or a resident, the phone would continuously ring, or her call would be directed to the
voicemail. The Ombudsman stated that these calls were not made during change of shifts.
During a concurrent observation and interview on 3/10/22, at 9:50 a.m., Unlicensed Staff O was observed
sitting on a chair behind a desk with a telephone and a computer. Unlicensed Staff O was observed
screening visitors and staff for signs and symptoms of COVID-19. Unlicensed Staff O would also ask
visitors and staff to have their temperatures checked and he would enter the results in his computer.
Unlicensed Staff O was also observed answering phone calls and directing the calls to the staff or the
residents. When Unlicensed Staff O was asked what his title was, he showed his ID which stated Screener.
Unlicensed Staff O was observed assisting a resident who was in a wheelchair and taking the resident to
the patio where the resident's visitors were waiting while no one was manning the desk for screening and
answering telephone calls.
Event ID:
Facility ID:
055853
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
Based on interviews, and record reviews, the facility failed to offer and document advance directives for 8 of
17 sampled residents (Resident 9, Resident 11, Resident 13, Resident 15, Resident 17, Resident 40,
Resident 57, and Resident 163). This failure had the potential to result in facility performing care and
services at residents' end-of-life that is inconsistent with the residents' best interests or preferences.
Findings:
During a review of medical records for Advance Directives, the following residents (Resident 13, Resident
15, Resident 17, Resident 40, and Resident 57) had no indication in their medical records that an advanced
directive was listed or offered to these residents upon admission.
During an interview on 3/9/22 at 11:30 a.m., the Social Service Director (SSD) stated she was not
responsible for obtaining the Advance Directives. When asked who the responsible party for Advance
Directives was SSD stated to check with the facility's Admissions Coordinator.
During an interview on 3/9/22 at 12:00 p.m., the Admissions Coordinator stated he was the responsible
person for admission documents and reviewed an audit checklist used to verify the facility had obtained a
resident's Durable Power of Attorney (DPOA). When further questioning the admission coordinator if he is
responsible to ask if the admitting resident has an advance directive. The admission coordinator stated, I
check for DPOA not the advanced directive. The admissions coordinator could not explain what the
Advance Directive is used for and suggested the Social Services Director (SSD) may know.
Review of the admission Audit check list indicates the admission face sheet should list an Advance
Directive.
During an interview on 3/9/22 at 2:45 p.m., the Director of Nursing (DON) was asked who was responsible
for ensuring residents recieved information about Advance Directives. DON stated the advanced directive is
started before a resident is admitted and the process is carried-over into the initial care conference.
During review of the medical records for Residents 13, 15, 17, 40, 57, and 163, no record indicated the
facility discussed advance directives with each resident at their initial care conference.
A review of Resident 11's POLST (Physician Orders for Life-Sustaining Treatment) form dated 1/12/21, the
advance directive part did not indicate if it was discussed or not with the resident or responsible party.
A review of Resident 9's POLST form dated 3/7/22, the advance directive part did not indicate if it was
discussed or not with the resident or responsible party.
A review of Resident 15's POLST form dated 1/3/17, the advance directive part did not indicate if it was
discussed or not with the resident or responsible party.
A review of Resident 163's POLST form dated 5/28/11, the advance directive part was not included in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
the POLST form.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 3/10/22, at 8:50 a.m., Licensed Staff D and Management Staff C were asked about
the process for the resident's advance directive. Licensed Staff D stated if upon admission the resident did
not have an advance directive, she would notify the Social Services. Management Staff C stated if a
resident did not have an Advance Directive upon admission and wanted to have one, she would call the
Ombudsman to help facilitate the formulation of an Advance Directive. Management Staff C further stated
she was responsible for making sure the Advance Directive was discussed or offered to the resident or
responsible party.
Residents Affected - Some
During an interview on 3/10/22, at 10:15 a.m., Management Staff C was asked the reason why the
Advance Directive part in the POLST forms were left blank or if the facility had documentation if Advance
Directive was offered to Residents 11, 9, 15 and 163. Management Staff C stated, if it was not there, then
it's not there.
A review of facility's Advance Directives policy dated 12/2016, it indicated, 1. Upon admission, the resident
will be provided with information concerning the right to refuse or accept medical or surgical treatment and
to formulate an advance directive if he or she chooses to do so. 2. If the resident is incapacitated and
unable to receive information about his or her right to formulate an advance directive, the information may
be provided to the resident's legal representative .5. Prior to or upon admission of a resident, the Facility
designee will inquire of the resident, his/her family members and/or his or her legal representative, about
the existence of any written advance directives. 6. Information about whether or not the resident has
executed an advance directive shall be displayed prominently in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one of the three sampled residents
(Resident 50) was provided support with activities of daily living (ADL). This failure resulted in Resident 50
staying in bed throughout the survey, which had the potential to cause development of a pressure injury.
Residents Affected - Few
Findings:
A review of Resident 50's current medical diagnoses indicated the following: dementia (loss of cognitive
functioning-thinking, remembering, and reasoning), muscle weakness, and difficulty walking.
During an observation on 3/7/22, at 11:30 a.m., Resident 50 was observed laying on bed, doing nothing.
During an observation on 3/7/22, at 3:46 p.m., Resident 50 was observed laying on bed sleeping.
During an observation on 3/8/22, at 10:29 a.m., Resident 50 was observed laying on bed, looking around
the room and playing with her blanket. At 11:35 a.m. Resident 50 was observed still in bed.
During an interview on 3/9/22, at 3:16 p.m., Management Staff S stated that Resident 50 did not get up on
wheelchair because she did not look comfortable sitting in a wheelchair due to positioning issues in the
wheelchair. Management Staff was asked if they referred Resident 50 to therapy department for positioning
in the wheelchair. Management Staff S stated she would mention it to the Rehabilitation Director.
During a concurrent observation and interview on 3/10/22, at 10:38 a.m., Resident 50 was observed
awake, but in bed and doing nothing. Unlicensed Staff T stated that Resident 50 did not get up on
wheelchair because of safety concern that Resident 50 leaned forward whenever in a wheelchair.
During an interview on 3/10/22, at 10:46 a.m., Licensed Staff J stated that Resident 50 had not been up on
wheelchair in a while because she leaned forward whenever in a wheelchair because of her leg
contractures and falling out of the wheelchair.
During an observation on 3/10/22, at 4:10 p.m., Resident 50 was observed with bilateral leg contracture,
with right leg bent up to her abdomen.
During an interview on 3/10/22, at 11:02 a.m., Management Staff U stated that Resident 50 had
rehabilitation therapy in February 2021, but did not try the customized wheelchair. Management Staff U was
asked the reason for not trying the customized wheelchair and she stated that Resident 50 did not want to
get up on a wheelchair. Management Staff U was asked if Resident 50 verbalized not wanting to sit up on
wheelchair and she stated resident did not verbalize it but was resistant with therapy.
A review of Resident 50's annual MDS (Minimum Data Set, an assessment tool used for residents in
Medicare or Medicaid certified nursing homes), dated 12/31/20, indicated: G0400. Functional Limitation in
Range of Motion coding 0. no impairment for lower extremity. Significant change MDS dated [DATE]
indicated, G0400. Functional Limitation in Range of Motion coding 2. impairment on both sides for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0676
lower extremity.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 3/10/22, at 11:30 a.m., Management Staff V stated that Resident 50's leg
contractures were developed in the facility.
Residents Affected - Few
A review of Resident 50's bedfast care plan dated 3/10/22, it indicated, Resident 50 is noted to be bedfast
[due to] residents contractures of the bilateral lower extremities. Activity care plan dated 4/1/21 indicated,
Resident 50 isn't getting up in a wheelchair due to being difficult to sit correctly.
During an interview on 3/11/22, at 8:27 a.m., Management Staff U stated that residents with contractures
did not have to be bedfast, and she was not aware that Resident 50 was bedfast.
During an interview on 3/11/22, at 9:30 a.m., Management Staff V was asked who determine if resident
was bedfast or not. Management Staff V stated that she put bedfast care plan on 3/10/22 because Resident
50 stayed in bed most of the time, but it was not the first time it was noted. Management Staff V further
stated there was no approach or intervention prior to 3/10/22 because there was no care plan.
A review of Resident 50's Physician Order Report dated 2/10/22-3/10/22, it indicated RNA (Restorative
Nursing Aide) program - Range of Motion Exercise PROM to B Lower/Upper Extremity to decrease risk of
contracture 2x/wk x 3 mo with start date 11/10/21 and end date 2/10/22.
During an interview on 3/11/22, at 8:57 a.m. Unlicensed Staff X stated she just started as RNA today and
did not know about the previous RNA documentation.
During a concurrent interview and record review on 3/11/22, at 9:16 a.m., Resident 50's RNA program flow
sheet documentation and RNA order history were reviewed. Management Staff W stated some RNA
documentations were missing and did not know why.
During an interview on 3/11/22, at 10:37 a.m., Management Staff Q stated there was no policy and
procedure for RNA program, contracture and bedfast.
A review of facility's Activities of Daily Living (ADLs), Supporting policy dated March 2018, it indicated, 2.
Appropriate care and services will be provided for residents who are unable to carry out ADLs
independently .b. Mobility (transfer and ambulation .) 5. Interventions to improve or minimize a resident's
functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and
recognized standards or practice.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure food items in the refrigerator
were labeled and dated. This failure had the potential to result in residents eating or drinking expired or
contaminated food items, which could cause gastrointestinal illness for the vulnerable residents.
Findings:
During a concurrent observation and interview on 3/7/22, at 10:28 a.m., the kitchen was observed with
Management Staff E. One carton of opened orange juice that was not dated was observed inside the drink
refrigerator. Management Staff E stated they can keep the opened orange juice for five days and it should
be dated. Four small disposable white cups/bowls with lids with food inside were observed in refrigerator
#1. Management Staff E was about to throw them away and Dietary Staff F stated those were Rocky Road
pudding and will be used for later.
During a concurrent observation and interview on 3/9/22, at 9:36 a.m., the nursing station refrigerator for
residents' snacks and supplement was observed with Licensed Staff D. One carton of half-filled Med-Pass
2.0 with received date 2/24/22 was found inside the refrigerator without a date indicating when the carton
had been opened. Three peanut butter sandwiches with a used-by date 3/3 were found inside the
refrigerator. One food container full of peanut butter sandwiches with made-by date 3/7, no used-by date,
and one food container full of Turkey and cheese sandwiches with made-by date 3/7, no-used by date, were
found inside the refrigerator. Licensed Staff D stated the food in the refrigerator was stocked by the kitchen
staff.
During an interview on 3/9/22, at 9:52 a.m., Management Staff E stated that the dietary aide and prep-cook
were responsible for checking and re-stocking the nursing station refrigerator daily in the afternoon.
Management Staff E stated sandwiches were considered fresh and could be used for three days.
Management Staff E further stated that CNAs (Certified Nursing Assistants) should check the used-by date
on items before serving the item to residents. Management Staff E also stated that licensed nurses should
put opened date on Med-Pass 2.0 to keep track of how long it could be used.
A review of facility's Food Receiving and Storage policy dated 10/2017, it indicated, 8. All foods stored in
the refrigerator or freezer will be covered, labeled and dated (use by date) .14. Food items and snacks kept
on the nursing units must be maintained as indicated .a. All food items to be kept below 41 F must be
placed in the refrigerator located at the nurse's station and labeled with a use by date. e. Other opened
containers must be dated and sealed or covered during storage.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an
observation on 3/9/22 at 9:20 a.m., Licensed staff J was observed taking a blood pressure cuff (B/P) from
medication cart #1 and taking a blood pressure on Resident (8); Licensed Staff J proceeded to administer
Resident 8's medications. Licensed Staff J then proceeded to take a B/P on Resident 13 the roommate of
Resident 8. No observation of cleaning the B/P cuff was observed in-between use from one resident to
another. Licensed Staff J was then observed wiping down the B/P cuff in preparation to take another B/P on
Resident 55. When questioning Licensed Staff J what the process is for cleaning durable medical
equipment, she stated we should wipe down the equipment in-between use from one resident to another.
When asked if she did that for Resident 8 and 13, she stated, Oh, no--I didn't. I forgot.
Residents Affected - Many
During a continued Med Pass observation on 3/9/2022 at 15:12 p.m., Licensed Staff K was observed taking
a B/P machine with an O2 saturation finger probe and take a resident's vital signs, medications were then
administered. Licensed Staff K was then observed entering another resident's room and took another set of
vital signs using the same equipment. No cleaning of the B/P cuff and O2 sat finger probe was observed.
Licensed Staff K was observed wiping down the B/P cuff and finger probe with a disinfectant wipe prior to
entering another resident's room. When questioning Licensed Staff K about the process for cleaning
durable medical equipment, she stated the vital signs machine should be cleaned in-between each
resident. When asked if she cleaned the machine in-between the last two residents she stated, sorry, No, I
should have cleaned the B/P cuff and Sat monitor after each use, I forgot.
2. During an observation on 3/7/22, at 3:35 p.m., one resident's room was observed with signage outside
the room indicating, PUI Unit Yellow Zone STOP, and further indicated the resident had been placed on
contact/droplet precaution (e.g., precautions staff take when a resident exhibits a risk of infection
transmissible through physical contact or through exposure to the resident's sputum and/or mucous).
During an interview on 3/7/22, at 3:35 p.m., Licensed Staff H was asked the reason for designating the
room as a yellow zone (area for residents under observation for Covid-19 signs and symptoms) and she
stated she will check with the IP (Infection Preventionist) nurse. Licensed Staff H came back and stated two
residents tested positive for Covid-19 (respiratory disease caused by SARS-CoV-2, spread from
person-to-person) and the other two residents were exposed, hence the room was yellow zone.
During an observation on 3/7/22, at 3:48 p.m., Management Staff C was observed entering the yellow zone
room with regular blue mask. Management Staff C donned (put on) gloves inside the room, but did not don
a gown, N95 particulate filter mask or face shield. Management Staff C opened the window blinds and
checked on one of the four residents.
During an interview on 3/7/22, at 3:52 p.m., Unlicensed Staff P stated she did not know why the yellow
zone room was on contact/droplet precaution.
During an interview on 3/9/22, at 10:13 a.m., Management Staff C stated she went inside the yellow zone
room to open the blinds and did not don proper PPE because she knew that residents will be taken off from
yellow zone soon and she did not perform resident care.
During an observation on 3/7/22, at 4:00 p.m., Licensed Staff G was observed entering a resident's room
on contact precaution for C-diff (Clostridium Difficile-inflammation of the colon caused by
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
bacteria) with gloves and did not don a gown. Licensed Staff G placed a wedge on the legs of Resident 52
who was on contact precaution.
During an interview on 3/9/22, at 10:40 a.m., Licensed Staff G stated she went inside Resident 52's room
without gown because she was told that the signage for contact precaution was removed. Licensed Staff G
did not answer when told that Resident 52 was still in contact precaution and signage was still there when
she entered the room.
During an interview on 3/10/22, at 9:45 a.m., Licensed Staff I stated that all staff entering resident rooms on
transmission-based precautions like contact for C-diff and yellow zone, must wear proper PPE to protect
themselves and others and to prevent the spread of infection in the facility.
A review of facility's Isolation-Initiating Transmission-Based Precautions policy dated August 2019, it
indicated, 3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or
designee) .d. Determines the appropriate notification on the room entrance door . (1) The signage informs
the staff of .instructions for use of PPE .e. Ensures that protective equipment (i.e., gloves, gowns, masks,
etc) is maintained outside the resident's room so that anyone entering the room can apply the appropriate
equipment. 4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection
Preventionist discontinues them, which occurs after criteria for discontinuation are met.
Based on observations, interviews, and record reviews, the facility failed to implement its policies and
procedures on infection prevention and control practices when:
1. An unlicensed staff did not perform hand hygiene and change her gloves between residents did not clean
and disinfect the vital signs equipment between residents and after using the equipment.
2. Two staff did not wear proper PPE (Personal Protective Equipment) upon entering two resident rooms
that were on transmission-based precautions.
3. Two licensed staff did not cleanse and disinfect vital sign equipment in-between residents and after using
equipment.
These failures did not ensure a clean physical environment for patient care and services, and had the
potential to result in an outbreak of infections and illnesses to all residents of the facility.
Findings:
1. During an observation on 3/9/22, at 9:54 a.m., in room [ROOM NUMBER] with Unlicensed Staff L, she
was observed taking the vital signs equipment to the room. Unlicensed Staff L performed hand hygiene and
donned gloves. Unlicensed Staff went inside the room and checked the vital signs of Resident 32. After
Unlicensed Staff L was done taking the vital signs of Resident 32, without removing her gloves and
performing hand hygiene and without cleaning and disinfecting the vital signs equipment, Unlicensed Staff
L proceeded to Resident 26 and checked her vital signs. After Unlicensed Staff L was done checking the
vital signs of both residents, Resident 32 asked Unlicensed Staff L to get clothes in her closet. Unlicensed
Staff L did not remove her gloves nor perform hand hygiene, opened the closet of Resident 32, took some
clothes and handed them over to the resident. After Unlicensed Staff L was done in room [ROOM
NUMBER], she removed her gloves, performed hand hygiene, and took the vital signs equipment in front of
the nurse's station to charge the equipment without cleaning and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
disinfecting them.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 3/9/22, at 10:05 a.m., with Unlicensed Staff L, she stated that she did not remove
her gloves and performed hand hygiene between residents. When Unlicensed Staff L was asked if the vital
signs equipment was cleaned and disinfected before she brought it room [ROOM NUMBER], she stated
she did not know if it was. Unlicensed Staff L stated she was trained to perform hand hygiene and change
gloves after each resident care and was aware about the cleaning and disinfecting of the vital signs
equipment between residents, but forgot to do it.
Residents Affected - Many
During a review of a facility document titled, Nurse Assistant Training Program Skills Check List, incorrectly
dated 12/31/2022, the document indicated that Unlicensed Staff L was checked-off on handwashing and
taking vital signs.
During an interview on 3/9/22, at 10:50 a.m., with Licensed Staff M, she stated that it was her expectation
that nursing staff perform handwashing between resident care and after using the vitals equipment.
Licensed Staff M stated that staff should wipe down the face of the monitor, the blood pressure cuff and
tubing, the pulse oximeter inside and out, and the no contact thermometer with bleach wipes per
manufacturer's instructions. Licensed Staff M stated, We wipe all of that down. Licensed Staff M stated that
if these steps were not followed, there was a potential for the transmission of infection.
During an interview on 3/10/22. At 11:57 a.m., with Licensed Staff N, she stated that it was her expectation
that nursing staff would perform hand hygiene between residents and clean and disinfect the vital signs
equipment between residents and after using the equipment.
During a review of a facility policy and procedure (P&P) titled, Cleaning and Disinfecting Non-Critical
Resident-Care Items, dated June 2011, the P&P indicated that, The purpose of this procedure is to provide
guidelines for disinfection of non-critical resident-care items . Non- critical items are those that come into
contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood
pressure cuffs, crutches, and computers . Reusable items are cleaned and disinfected or sterilized between
residents (e.g. stethoscope, durable medical equipment) .Manufacturer's instructions will be followed for
proper use of disinfecting products .
During a review of a facility policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated August
2015, the P&P indicated, The facility considers hand hygiene the primary means to prevent the spread of
infections. The policy interpretation and implementation indicated, Use an alcohol-based hand rub
containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the
following situations: .Before and after direct contact with residents .After contact with resident's intact skin
.After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident .After removing
gloves .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview and record review, the facility failed to ensure all areas of the facility were
safe, sanitary, of comfortable, when facility staff allowed one resident's (Resident 61) room to become
cluttered and odiferous. This failure resulted in added safety risk to Resident 61 related to obstacles in the
physical environment that posed a risk to timely evacuation in time of emergency, as well as a strong,
foul-smelling odor emitting into the adjacent hallway through the doorway of the resident's room.
Findings:
During an observation on 3/7/22, at 11:35 a.m., Resident 61's door was observed closed. When opened,
there was a distinct foul odor that appeared to be coming from a wound. Resident 61's room was observed
full of stock boxes and cluttered personal items.
During an interview on 3/7/22, at 11:35 a.m., Management Staff Q stated that Resident 61 had several
wounds and last assessment was December 2021, because Resident 61 would not let staff assess the
wounds.
During a concurrent observation and interview on 3/7/22, at 11:50 a.m., Resident 61 was observed sitting
on the bed, playing video game. Resident 61 stated he was stayed in the facility for eight-and-one-half
years and he allowed staff to look at his wounds and that dressing changes were done two-to-three times
each day.
During an interview on 3/7/22, at 12:25 p.m., Licensed Staff D stated that Resident 61 refused wound care
treatment and that staff and physician were aware of the foul odor in the room.
During an observation on 3/7/22, at 12:52 p.m., Licensed Staff D offered to do wound care treatment in the
afternoon, and Resident 61 refused saying probably be asleep.
During an observation on 3/10/22, at 10:41 a.m., Licensed Staff D offered to do wound care treatment, and
Resident 61 stated he already did it 30 minutes ago.
A review of Resident 61's PRESSURE ULCER CARE PLAN dated 10/20/20, it indicated presence of stage
4 (full thickness loss of skin and tissue, with exposed or directly palpable bone) pressure injuries to left and
right buttocks and to rectal area. Pressure ulcer care plan indicated, Admittance to SNF (Skilled Nursing
Facility) with pressure ulcers; preferences which are not in the best interest of wound healing .declining to
take a shower; preference to stay in bed all day; preference to decline wound care treatments as ordered;
preference to lay in bed on one side for hours; preference to not go out to the wound care center;
incontinence episodes with resident preferring to do all incontinence care.
During an interview on 3/9/22, at 11:00 a.m., Housekeeping Staff R stated that Resident 61 refused
cleaning of the room, and the Housekeeping Supervisor was aware of it. Housekeeping Staff R stated that
whenever he passed by Resident 61's room, he could smell a foul odor like something was rotten even
though the door was closed.
During an interview on 3/9/22, at 11:41 a.m., Resident 61 stated that he wanted all his belongings
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055853
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Redwood Cove Healthcare Center
1162 S Dora St.
Ukiah, CA 95482
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
kept in his room and denied there was foul odor in his room.
Level of Harm - Minimal harm
or potential for actual harm
A review of facility's Deep Clean Checklist undated, it indicated, Clean whole area/room using disinfectant
(Virex II). Dwell time is ten minutes .Order of cleaning .Window sills, top closet, closet inside and out, light
fixture/light button, call lights, bed frame and mattress, bedside table, over bed table, floor.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055853
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
20 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
- 0342GeneralS&S Dpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0346GeneralS&S Bno actual harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Bno actual harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0024GeneralS&S Dpotential for harm
Establish policies and procedures for volunteers.
- 0341GeneralS&S Dpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
- 0352GeneralS&S Dpotential for harm
Properly install and monitor supervisory attachments on automatic sprinkler systems.
FAQ · About this visit
Common questions about this visit
What happened during the March 11, 2022 survey of REDWOOD COVE HEALTHCARE CENTER?
This was a inspection survey of REDWOOD COVE HEALTHCARE CENTER on March 11, 2022. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at REDWOOD COVE HEALTHCARE CENTER on March 11, 2022?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Conduct testing and exercise requirements."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.